Blue toe in a male with cholesterol embolisation syndrome

A 77-year-old man presented with peripheral oedema and was found to have impaired renal function. He had a background of hypertension, ischaemic heart disease and diabetes. Since a coronary artery bypass operation 3 years ago he had been treated with warfarin.

He was found to have an elevated serum creatinine (424.3 mmol/l) and eosinophilia (33% of white blood cell count of 4,900/mm³).

During his inpatient stay, he developed a characteristic blue toe sign in his toes (Fig 1a). Cholesterol embolisation was suspected and warfarin was stopped but the patient's renal function continued to deteriorate. Low-density lipoprotein apheresis and continuous haemofiltration were started and the eosinophilia and acute kidney injury gradually improved. However, the patient unfortunately died 10 days after intensive treatment.

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Fig 1.

(a) In the course of admission (approximately 3 weeks), characteristic blue toe sign occurred at the toes. (b) Macroscopic autopsy revealed fulminant renal infarction at the lower part of the left kidney. (c) Microscopic histology revealed typical cholesterol crystals in the aorta and (d) in the renal arcuate artery.

Post-mortem examination revealed fulminant renal infarction at the lower part of the left kidney (Fig 1b). Microscopic histology revealed typical cholesterol crystals in the aorta (Fig 1c) and the renal arcuate artery (Fig 1d).

Cholesterol embolisation syndrome (CES) is a systemic disease which occurs when cholesterol crystals and other contents of an atherosclerotic plaque embolise from a large proximal artery to smaller distal arteries, causing ischaemic end-organ damage.¹ Diabetes and increasing age are thought to be predisposing factors.² In this case, the trigger of cholesterol embolism was thought to be warfarin administration. To date, no specific diagnostic test, other than clinical signs and biopsy for CES has been developed.³ Peripheral cutaneous involvements, such as blue toe is one of specific findings and a clue for prompt and accurate diagnosis.

• © 2014 Royal College of Physicians